20 October 2008

Belly pain is one of those thing that is so common and so typically benign that it's easy to forget how bad it can be sometimes. I saw a fellow recently who gave me a little refresher in "The Bad Abdomen." He showed up in the patient tracking system without a lot of other information (the nurse had not yet completed the computer documentation). Ordinarily, I would not have sprinted right in, but I was not terribly busy and I'm a restless sort, so I went in right away. This guy was sick, one of those cases where you walk in the room and stop dead in the doorway at the sight of him. He had abdominal pain, a terrible pain which had come on suddenly a few hours ago, and he was trying to hold perfectly, still like a statue, despite the pain which contorted his face. His respirations were deep and fast, and the sawtooth lines on the heart monitor bespoke a heart rate twice what it should have been. His skin was gray and moist, and his blood pressure was in the mid double-digits.

Not a diagnostic dilemma. A classic acute abdomen due to a perforated viscus, with early septic shock. I was on the phone with the surgeon within ten minutes of the patient's arrival, and a well-practiced team of nurses had the patient stabilized shortly thereafter: IV fluid bolus, blood transfusion, antibiotics, pain medicine, vasopressors. His CT scan was impressive.

For the uninitiated, the black at the top is free air, which has escaped the gut and is in the abdominal cavity; there is a lot of fluid in the belly as well, probably intestinal contents, and the bowel wall looks boggy and has air in it, which is an ominous sign.

The surgeon arrived, ready to go to work, and went to see the patient. He came out of the room a few minutes later, bemused. "Get this," he said to me, "this guy is refusing surgery!""Are you kidding me? He's gonna die!""He's serious. I told him he would die without an operation, but he still says no. Put him in the ICU and let me know if he changes his mind." And with that the surgeon was gone.

Now this was strange. This fellow was young and otherwise healthy, and the odds were that he would make a complete recovery with a timely operation. Without the operation, death was certain. Why didn't he want surgery? I went in to talk with him.

As the surgeon had said, the patient was dead set against it. I asked why, and grimacing from the pain, he said, "Doc, I know my body, and I've just got to listen to my body. Can't you understand that? Just give me some time, let me get hydrated, give me some juice, and my body will heal itself. I don't need no surgery." I explained to him, clearly and carefully, that he was going to die without the operation, and I asked him to repeat that back to me so I could know he understood what I was telling him.

He did. He understood me just fine. He just didn't believe me. He elaborated, "Doc, I just know this, I've been through it before. You give me some juice and leave me to rest tonight, and I'm gonna be just fine in the morning." No explanation I gave him could convince him otherwise. I figured it might be inadequate pain control, so we gave him some more pain meds to try see if that would allow him to focus more clearly. No luck. I had a nurse who seemed to have rapport with him spend some time talking him about it. No luck. Deep down, this man just didn't believe that he was going to die. I got him a bed in the ICU, and figured I'd give it one last go before he went upstairs.

"Okay sir, before you go up I've just got some paperwork to complete. Do you have a next of kin?""Um, yeah, my sister.""Great. What's her phone number? We'll be needing to call her later. Do you have a mortuary or funeral home selected, or should we just have your sister pick one?""Um, I don't think -""No problem, we'll just have her pick one. Now, in a few hours, you're not going to be able to breathe any more, and if we're going to keep you alive, we'll have to put you on life support. Do you want us to do that, or should we let you suffocate?""That sounds bad -- I don't want to suffocate.""Right, then, the ventilator it is. But a few hours after that, your blood pressure is going to go really low and your heart will stop. Do you want us to pound on your chest and shock your heart to try to bring you back? It won't work, of course, but I just need to let the ICU doctor plan how to handle it when the time comes. So should we do CPR or not?"He gave me a long look. "You really mean it, don't you?" I said nothing, but let the long silence linger. "You really think I need the surgery?" I nodded. He sighed, and slumped back, resigned,"Well, all right, if you really think I need it...""You do. It may save your life. I'll let the OR know.""Does this mean I don't get my juice?""Not till tomorrow.""OK."

I've saved many lives (or at least prolonged them) through medical skills and diagnostic acumen. In this case, I was pleased and amused that I saved (or at least prolonged) his life through my skills at manipulation and blunt force persuasion. A useful job skill, one underappreciated in medical training: the ability to discern when to let the patient have their way, and when to bully them into making the right choice.

[Note: there are times when a patient may make a principled choice against surgery. They may have an incurable disease, or very high surgical mortality, or simply be old and ready to die. I respect those choices. This was different in that it was not a principled decision, but the patient's denial that had to be overcome.]

whitecap nurse says: what a beautiful example of the three requirements for successful communication: 1)ability to HEAR the words, 2)ability to UNDERSTAND the language, 3)BELIEVING what the speaker says is true. It is pretty easy to achieve #1&2 most of the time but #3 can be a stickler! Thanks for persevering in this case! He really needed you to do that.

Bravo, doc. You are not a bully. You told the patient the truth he needed to hear, in a way that made it more understandable to him. The result; he made a wise decision instead of a foolish one. You can't do better than that.

By way of simile; we have an evacuation plan in my building. I am one of the people whose job it will be to convince people that this is for real and they really need to get out. NOW! Same problem; denial. We have been taught to carry a bunch of Sharpies in our pockets, and, when someone indicates that he is not leaving, we are to hand him a Sharpie and say, "well, O.K. Just do us a favor and write your name and social security number on your inner arm. It will speed up identification." We are then to move on, and leave him to reevaluate his options.

He clearly needed to hear that. I just had a patient die yesterday from a ruptured sigmoid. Terrible stuff. She even had an operation, but she couldn't survive it due to the large original insult, the time elapsed before presentation, and her underlying co-morbidities. Really sad.

That's a great case. I don't disagre with anything you did, but it highlights the fact that the doctor-patient relationship isn't really an equal partnership. The doctor has much more power in this type of interaction.

Shadowfax

About me: I am an ER physician and administrator living in the Pacific Northwest. I live with my wife and four kids. Various other interests include Shorin-ryu karate, general aviation, Irish music, Apple computers, and progressive politics. My kids do their best to ensure that I have little time to pursue these hobbies.

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